title: Unprotected carotid artery stenting in modern practice.
abstract: OBJECTIVE
  Embolic protection devices (EPD) may provide a mechanism to reduce peri-procedural strokes. They are advocated by consensus guidelines and mandated for Medicare reimbursement. However, outcomes data remain mixed. We aimed to characterize the population of patients undergoing unprotected carotid artery stenting (CAS) and assess the utility of distal filter EPD (F-EPD) in elective CAS.
  
  
  METHODS
  We analyzed patients enrolled in the CARE Registry® undergoing CAS between May, 2005 and January, 2012. We assessed the relationship between distal F-EPD use versus no use (No-EPD) and the composite of in-hospital death or stroke (MAE) in unadjusted and 1:3 propensity-matched analyses.
  
  
  RESULTS
  Embolic protection was not attempted in a total of 579 out of 13,263 cases performed (4.4%). Patients in the No-EPD group had worse preprocedure neurologic risk factors including higher rates of acute evolving stroke, prior TIA/stroke, symptomatic lesion status, spontaneous carotid artery dissection, and use of general anesthesia intraprocedurally (all Standardized Differences{sd} >10). After exclusion of nonelective cases there was no significant difference in MAE between the No-EPD and F-EPD groups (1.6% vs. 2.3%, sd = 4.72). Additionally, after propensity matching, rates of MAE did not differ between the No-EPD (n = 355) and F-EPD (n = 1065) groups (1.7% vs. 2.5%, sd = 5.87).
  
  
  CONCLUSIONS
  Patients selected to undergo unprotected CAS in contemporary practice have high rates of adverse preprocedure neurologic risk factors. Our propensity-matched analysis did not demonstrate evidence of significant benefit or harm associated with use of F-EPD in elective CAS patients.
authors.affiliation: Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Jay
authors.initials: J
authors.lastname: Giri
authors.forename: Robert W
authors.initials: RW
authors.lastname: Yeh
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Kennedy
authors.forename: Beau M
authors.initials: BM
authors.lastname: Hawkins
authors.forename: Ido
authors.initials: I
authors.lastname: Weinberg
authors.forename: Mitchell D
authors.initials: MD
authors.lastname: Weinberg
authors.forename: Sahil A
authors.initials: SA
authors.lastname: Parikh
authors.forename: Joseph
authors.initials: J
authors.lastname: Garasic
authors.forename: Michael R
authors.initials: MR
authors.lastname: Jaff
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: White
authors.forename: Kenneth
authors.initials: K
authors.lastname: Rosenfield
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D057505:Embolic Protection Devices; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D020766:Intracranial Embolism / Q000209:etiology / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D057216:Propensity Score; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
keywords: carotid artery stenosis; carotid artery stenting; embolic protection devices